Revision 20-4; Effective October 1, 2020

CHIP and CHIP Perinatal

A request for review (RFR) is any expression of dissatisfaction with an adverse action taken by HHSC.

Following an adverse action taken on a CHIP EDG, HHSC sends a disenrollment or denial letter to the family. The letter informs the CHIP household of its right to request a review.

Households have 30 business days from the date of Form TF0001, Notice of Case Action, to submit a written request for review concerning the decision that resulted in an adverse action. Households can submit the written request for review by:

• faxing the request to 866-559-9628; or
• mailing the request to:
  • Texas Health and Human Services Commission
    P.O. Box 149027
    Austin, TX 78714-9027

The request must come from the head of household or authorized representative or the child’s provider or health plan (for expedited situations). If the child's physician or health plan determines that a suspension or termination of enrollment could seriously jeopardize the child's life, health or the ability to attain, maintain or regain maximum function, the household is entitled to an expedited review process. When disenrolled at the six-month income check, the household has 30 business days from the date of Form TF0001 to submit a request for review.

Allow continued enrollment for all people when HHSC receives the request for review anytime from the first day of the last benefit month through cutoff of the last benefit month.

Exception: A household is not eligible for continued enrollment if the household was denied for failure to provide information requested during a six-month income check.

Related Policy

Six-Month Income Check, D-1500
Exceptions to the Continuous Enrollment Period, D-1731

 

D—1921 Request for Review Processing

Revision 20-4; Effective October 1, 2020

CHIP and CHIP Perinatal

If any member of a household or the household's representative expresses dissatisfaction with a decision regarding benefits or services, take the following action:

• explain the basis for the decision and the applicable policies;
• provide the household an opportunity to have a conference with the supervisor;
• provide the household an opportunity to request a review; and
• consult with the supervisor if the person requests information considered confidential.

Note: The member is entitled to any information used to determine suspension, reduction or termination of benefits. See B-1210, Disclosure of Information, for information considered confidential.

Upon receipt of the request for review, review the adverse action and send Form H1063, Request for Review Outcome Letter, within 10 business days from the date of receipt of the request. The response letter contains information addressing the answer to the request for review. Document the final decision.

When the request for review is received, validate that the person requesting the review has case authority.

• If a person with case authority requests the review in writing, request-for-review staff review all case information and supporting evidence that the household provides. Make a determination and send Form H1063 informing the household of the decision.
• If the person requesting the review does not have case authority, deny the request and send Form H1063 to inform the household of the request for review denial.

Review all case information and supporting evidence the household provides. If the case was processed accurately, deny the request for review. Send Form H1063 to inform the household of the request for review outcome.

If the EDG was not processed accurately or the person submitted additional information with the request for review that changes the eligibility outcome, approve the request for review and take the necessary action to re-establish eligibility or enrollment. Send Form H1063 and Form TF0001, Notice of Case Action, to inform the household of its eligibility.

When the request for review is approved and the reason for the request is related to a disenrollment decision, review the child's current status to determine if the child is currently enrolled. If the child is:

• currently enrolled, advise the Enrollment Broker to cancel the disenrollment for the future month to ensure the child's enrollment continues through the end of the current enrollment period and generate Form H1063. In addition, the Enrollment Broker will send an Enrollment Confirmation Notice.
• not enrolled due to renewal period ending adversely, request-for-review staff process the CHIP eligibility and send Form H1063 and Form TF0001 to inform the household of CHIP eligibility. The Enrollment Broker re-enrolls the child for another 12-month period and once enrollment is re-established, the Enrollment Broker will send an Enrollment Confirmation Notice.

When HHSC receives a request for review after 30 business days from the date of Form TF0001 or determines that the request for review is not for an adverse action, deny the request and generate Form H1063 to inform the household of the denial reason.